Surgical Respiratory Diseases Flashcards
What are the features of Brachycephalic Obstructive Airway Syndrome (BOAS)?
Stenotic nares Overlong soft palate Enlarged tonsils Everted laryngeal saccules Hypoplastic trachea Hiatal hernia Stertor / Stridor \+/- laryngeal collapse
Describe narrow nares in BOAS.
Dramatically increase resistance to air flow into the nose
Cartilage supports of the nares tend to collapse during inspiration, requiring even more effort to breathe
Describe laryngeal collapse in BOAS.
Progressive collapse of the larynx
Graded in terms of severity from 1 (least severe) to 3 (most severe)
Rate of progression may be able to be slowed with appropriate treatment
Describe an overlong soft palate in BOAS.
Can partially obstruct air flow into the trachea and cause turbulent airflow in the area of the larynx
What nursing/owner considerations should we have for BOAS patients?
Avoid stress/heat Use harness, not collars Achieve/maintain ideal bodyweight Carefully managed exercise regimes Oxygen therapy Owner education (signs of respiratory distress)
What should we assess pre-operatively in BOAS patients?
TPR
MMs and CRT
SpO2
Clinical signs of BOAS/assessment with vet - ASA grading
What surgical options do we have to treat BOAS?
Soft palate resection (staphylectomy)
Tonsil resection
Removal of everted laryngeal saccules
Nostril resection (correct stenotic nares)
Laster assisted turbinectomy (LATE)
(May be performed together as multilevel surgical correction)
How do we prepare pre-BOAS surgery?
Full discussion with vet (ASA grading)
Informed consent - high risk surgery
Full analysis of biochem/haem
Pre-oxygenate for at least 5 mins - delays O2 desaturation at induction
Minimal stress via handling (IV catheter after premed if needed)
Peri-operatively - ocular lubrication + intensive monitoring
How do we prepare for BOAS surgery?
Ensure all equipment prepared (lighting, laryngoscope, rescue ET tube)
Thoracic radiography
Minimal - no hair clip/scrub
Positioning - sternal, head raised using drip stands
Be ready for regurgitation - tilted table/suction
What monitoring should be carried out peri-operatively?
O2 saturation (>98%)
Capnography - ETCO2 (35-45mmHg)
Use IPPV/mechanical ventilator as appropriate (consider circuit selection)
Blood pressure - mean > 60 mmHg (consider bolus IVFT if indicated)
Ocular lubricant frequently applied
What complications can occur post-BOAS surgery?
Airway swelling
Vomiting and regurgitation
Aspiration pneumonia
How do we recover BOAS patients post-op?
Extubation later than usual
Monitor O2 saturation
O2 supplementation post-extubation (mask/flow-by)
Sternal recumbency, head elevated
Suction available
Intensive monitoring charts - constant supervision
How should BOAS patients post-op be managed at home?
Harness
Restricted exercise 5-10 mins twice daily - 6 weeks
Examination 2 and 10 days post-op
Wet solid food 6 weeks post-op - limit airway irritation
What are the causes of laryngeal paralysis?
Ageing changes (degenerative neuropathy) - idiopathic
Congenital disease
Trauma (bite wounds, neck surgery)
Cancerous infiltration of nerve that controls the muscle
What are the signs of laryngeal paralysis?
Exercise intolerance Noisy respiration Coughing, gagging Change/loss of vocal sounds (dysphonia) Dysphagia Cyanosis and collapse - if severe
How do we manage mild cases of laryngeal paralysis?
Anti-inflammatories Antibiotics - where indicated Sedative Raised feeding Reduce stress and manage exercise
How do we manage severe cases of laryngeal paralysis?
Unilateral arytenoid lateralisation (laryngeal tie-back)
-Diagnosis under light plane of anaesthesia
-Surgery performed on left side of neck
Left arytenoid cartilage permanently tied open
How do we care for laryngeal paralysis patients post-op?
Small, regular soft meals
Avoid dusty food/atmospheres
Raised feeding/water
Wound management
What should we tell owners post-unilateral arytenoid lateralisation surgery?
Discuss permanent change in phonation No swimming (risk of aspiration too great) Prognosis positive unless systemic neuromuscular disorder
What are the two types of palate defects?
Congenital, e.g. clefts of upper lip, hard and/or soft palate (clinical signs = difficulty feeding and nasal discharge)
Acquired, e.g. trauma, RTAs
How do we treat congenital palate defects?
Surgery performed at 3-4 months
Closure of tissues separating the oral and nasal passages with minimal tension
Haemorrhage not uncommon
How do we treat acquired palate defects?
Primary (surgery) or secondary (healing) closure.
What surgical options do we have for tracheal collapse patients?
Extraluminal ring prosthesis
Intraluminal stent
Describe an extraluminal ring prosthesis.
Invasive - risk management
Complications = vascular damage, tracheal ring migration, coughing, dyspnoea, laryngeal paralysis (due to iatrogenic nerve damage)
Describe an intraluminal stent.
Less invasive surgery than extraluminal ring prosthesis
Durable material but can fatigue under pressure (e.g. repeated coughing)
Complication = excessive inflammatory tissue around trachea
Vital to control coughing post-surgery
How do we prep a patient for extraluminal ring prosthesis surgery?
Surgical preparation (aseptic) Ventral neck - large area Dorsal recumbency Discuss complications Pre-oxygenation Careful handling Calm/stress-free
How do we prep a patient for intraluminal stent placement?
Lateral recumbency Fluoroscopic guidance Pre-oxygenation Careful handling Calm/stress-free
Describe a lateral thoracotomy.
Surgical incision performed between the ribs
Provides excellent view of one side of the thorax
Indications = lung lobectomy (abscessation/lung lobe torsion/neoplasia)
Describe a median sternotomy.
Surgical incision through sternum
Provides view of bilateral thorax
Indications = pyothorax/mediastinal masses/heart surgery
What are the indications for an emergency tracheostomy?
Facilitate anaesthesia when airway is compromised
Stabilise patient and allow airway management
Provide definitive airway until swelling/obstruction is resolved
Laryngeal paralysis/BOAS/foreign body/laryngeal trauma
How do we care for a tracheostomy tube?
24/7 monitoring - maintenance, comfort, asepsis
Prevent build-up of secretion - suctioning, regular cleaning/changing tube
Initially every 15 mins, once stable every 4-5hrs
What should we be continually checking for in patients with a tracheostomy tube?
Harsh respiratory sounds Dyspnoea Distress Coughing Discharge Discomfort Stoma - pain, swelling, heat
How do we suction a tracheostomy tube?
Pre-oxygenate for min 5 mins
Aseptic technique
Sterile long, soft catheter - pre-measured no longer than top of trach tube
Once catheter in place, turn on suction unit
Move catheter in circular motion as withdrawing (15 secs)
Why and how do we humidify tracheostomy tubes?
Bypassing normal humidification in URT
Drying can cause damage to mucosa (inflammation, irritation, thick mucus)
Humidification filters if available, attached to tube
0.5-3mls sterile isotonic saline - discussion with vet
Nebulisation - sterile saline 10mins every 2-3hrs
